O0110A10c: Chemotherapy - Other - At Discharge, Step-by-Step
Step-by-Step Coding Guide for O0110A10c: Chemotherapy - Other - At Discharge
1. Review of Medical Records
Objective: Confirm whether the resident received any chemotherapy treatments classified as "Other" at the time of discharge.
Actions:
- Access the resident’s medical records, including discharge summaries, treatment logs, and physician orders.
- Verify documentation of chemotherapy administered during the last three days before discharge. Ensure that the chemotherapy was administered by a route other than IV or oral, such as intramuscular, intraperitoneal, intrathecal, or topical.
2. Understanding Definitions
O0110A10c: Chemotherapy - Other: This item captures chemotherapy administered by any non-oral and non-IV methods during the resident’s last three days before discharge. Possible routes include:
- Intramuscular: Injection into the muscle
- Intraperitoneal: Injection into the peritoneal cavity
- Intrathecal: Injection into the space surrounding the spinal cord
- Topical: Application of chemotherapy directly to the skin.
Illustration 1:
Scenario: A resident was undergoing intrathecal chemotherapy for leukemia. This treatment continued during the three-day discharge window.
Result: O0110A10c is coded "Yes" because intrathecal chemotherapy falls under the "Other" category.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records to confirm that chemotherapy was administered within the three-day period before discharge.
- Step 2: Verify that the chemotherapy was administered by a method other than IV or oral.
- Step 3: If chemotherapy was administered by an alternative method (e.g., intramuscular, intrathecal), check O0110A10c as "Yes".
- Step 4: If no such chemotherapy was provided, mark "No".
Illustration 2:
Scenario: A resident received oral chemotherapy as part of their treatment but did not receive any other forms of chemotherapy at discharge.
Result: O0110A10c is coded "No", as oral chemotherapy is coded separately.
4. Coding Tips
- Ensure Correct Categorization: Only non-IV and non-oral chemotherapy should be coded under O0110A10c.
- Review Physician Orders: Check for specific orders detailing the administration route of chemotherapy, as this impacts coding.
5. Documentation
Objective: Ensure that the administration of chemotherapy is properly documented and categorized as "Other" for the last three days prior to discharge.
Actions:
- Record the route of chemotherapy (e.g., intramuscular, topical) and the date it was administered.
- Include details such as dosage, frequency, and any complications related to chemotherapy treatments.
Illustration 3:
Scenario: A resident received intramuscular chemotherapy on the day before discharge, documented with specific details on dosage and administration route.
Documentation: The administration is properly logged, and O0110A10c is coded "Yes".
6. Common Errors to Avoid
- Confusing Routes of Administration: Ensure that only chemotherapy administered by non-oral and non-IV methods is coded here.
- Incomplete Documentation: Do not code without clear and complete documentation of the chemotherapy type and route.
Illustration 4:
Scenario: A resident's records mention chemotherapy treatment, but the route of administration is not specified.
Error: Lack of specificity can lead to incorrect coding. Always confirm the administration route before coding.
7. Practical Application
- Example 1: A resident was discharged after receiving intrathecal chemotherapy for central nervous system involvement. O0110A10c is coded "Yes".
- Example 2: A resident was on oral chemotherapy and did not receive any intramuscular or topical chemotherapy before discharge. O0110A10c is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set O0110A10c was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
